1114010949 NPI number — VITREO-RETINAL MEDICAL GROUP, INC.

Table of content: (NPI 1114010949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114010949 NPI number — VITREO-RETINAL MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITREO-RETINAL MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MODESTO RETINA CENTER, INC.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114010949
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 PARK CENTER DR STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95825-8341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-596-2027
Provider Business Mailing Address Fax Number:
866-913-6557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4712 STODDARD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95356-9404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-549-8444
Provider Business Practice Location Address Fax Number:
209-549-8443
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PEARLMAN
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
916-596-2027

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207WX0107X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CP5300 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ32011Z . This is a "WORKERS COMP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0199873 . This is a "DEPT. OF LABOR WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0030323 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ29020Z . This is a "BLUE SHIELD CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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